Understanding Insurance Coverage for Catheter Users

Understanding insurance coverage for urinary intermittent catheters can be confusing. There are different types of urinary catheters with different prescription codes. Coverage rules and requirements are different for each code - and those rules may vary from insurer to insurer.

Catheter Coverage: What you need to know.

Intermittent Catheters: Documentation Requirements

Disclaimer

Disclaimer: The information in this document is informational only, general in nature, and does not cover all payers’ rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This document represents no promise or guarantee by Coloplast Corp. regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient’s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-Medicare coverage situations

A doctor’s order or prescription is required to get your intermittent catheter supplies and to begin the claims process. This would include the beneficiary’s name, detailed description of the item including brand name and type of catheter, quantity used per day and month, treating diagnosis, signature of treating physician, and date the order was signed.

Coloplast strongly encourages clinicians to indicate the appropriate “dispense as written” language as designated by your state’s Pharmacy Board. This will require the supplier to fill the order with the catheter you and your patient have chosen to meet their needs.

Additional medical records which support permanent urinary incontinence or urinary retention or information supporting medical necessity for higher utilization than described may also be necessary. Also, support for the type of catheter prescribed should be indicated in the patient’s chart notes. If the patient is using a Coudé tip, notes should detail why the patient can not use a straight tip catheter. Some common reasons may include strictures, false passages, an enlarged prostate, or documented difficulty passing a straight tip catheter. If a closed system is needed, thorough documentation of why a sterile kit is required needs to be in the chart notes. This may include information on things like past UTI’s or the use of immunosuppressing medications.

Intermittent catheters are considered under Medicare to be a Prosthetic Benefit. That is, they replace all or part of an internal body organ or part of the function of a permanently inoperative or malfunctioning internal body organ. In order to meet the basic coverage criteria an individual must have permanent urinary incontinence or urinary retention.

Whether or not a supplier accepts assignment for a given product is a decision made by the supplier. By accepting assignment, the supplier is electing to accept the Medicare allowed amount as the full reimbursed amount allowed. This image illustrates how a supplier, billing $3 for a catheter will be paid in the instance of accepting assignment or not accepting assignment. Accepting assignment is a concept exclusively when Medicare as the payer, but this can be used to illustrate how in and out of network benefits work for some private insurance patients. In the above image, Medicare will pay for 80% of the Medicare allowed charges for a given item or service. This means that the patient or their secondary or supplemental insurance plan is responsible for a 20% coinsurance. As you can see, our supplier could be supplying a Self Cath, SpeediCath or red rubber—for reimbursement purposes they are all the same—All are coded A4351, and the set allowed amount is $1.80 (actual reimbursement rates will be different, $1.80 is used as a reference point). Even though the supplier billed $3.00 as their retail amount or “billed charges”, the set reimbursement allowed amount is $1.80. This in effect becomes the new sale price. Because the supplier is accepting assignment, or for private insurance in-network, they are bound to accept the Medicare allowed amount as the payment in full amount. They are required to write off the $1.20 difference between the retail or billed charge of $3 and the allowed amount of $1.80. In the case of Medicare, as shown in our example, medicare pays the supplier 80% of the allowed charges. The patient (or the patient’s supplemental secondary insurance plan) is responsible for the other 20%. So the supplier receives $1.44 from Medicare and has to bill the patient the other $.36.

Now we move to a supplier who is not accepting assignment. The $3.00 retail price is the same. The set reimbursement from Medicare is the same $1.80. What is different is that because the supplier is choosing to not accept assignment they can and often WILL hold the patient responsible for the difference between the retail or billed charge and the allowed amount. Also, in cases like the for Medicare, the patient will be required to pay the full $3.00 up front to the supplier and will be forced to file their own claim to Medicare. Once Medicare reimburses the $1.44 directly to the patient, which again is 80% of the allowed $1.80, the patient has now paid $1.56 when they could have paid $.36 for the exact same catheter.

Frequently Asked Questions

Question: How many catheters can I get per month?

Medicare will allow for the usual maximum of 200 catheters per month or one catheter for each episode of catheterization. Other payers allowed catheters per month may differ from Medicare’s, so it is important for you to check with your insurance plan to see how many catheters your plan allows.

Question: What does usual maximum number of supplies mean? Does this mean that every beneficiary should get 200 per month?

No. The usual maximum number represents a determination of the number of items that beneficiaries with extreme utilization requirements will actually need. The typical beneficiary will require a much lower amount. The beneficiary’s utilization should be determined by the treating physician based upon the patient’s medical condition. There must be sufficient information in the medical record to justify the amount ordered.

A beneficiary or caregiver must specifically request refills of urological supplies before they are dispensed. The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis, even if the beneficiary has “authorized” this in advance. The supplier should check with the patient or caregiver prior to dispensing a new supply of intermittent catheters to determine that previous supplies are nearly exhausted.

Question: My supplier is working with me since I have a history of urinary tract infections (UTI), I am currently washing and reusing catheters (A4351, A4352) - i.e., using clean technique. I am just waiting for my doctor to send the lab results along with the UTI dates. Sometimes it takes 3 to 4 weeks for the doctors to respond to these requests. Are sterile catheter kits (A4353) covered for people in my situation?

Not typically. To qualify for a closed system or kit, an end user must meet the current criteria in order to be eligible for reimbursement. Beneficiaries who have been reusing intermittent catheters (A4351, A4352) with clean technique at the rate of one catheter per week are eligible to use a sterile catheter (A4351, A4352) and a packet of sterile lubricant (A4332) for each catheterization. The number of items needed must be determined by the treating physician and information in the medical record must justify the need for the number of items prescribed.

Question: I have been unable to catheterize using a straight tip catheter and now require a coude tip, is there additional documentation necessary for coverage?

Yes, medical documentation is required to support the necessity for a coude tip rather than a straight tip. This should be documented in your medical history file with your physician and can be descriptive of your inability to successfully pass a straight tip catheter or as the result of urethral strictures.

The current Medicare guidelines indicate that a coude tip is rarely medically necessary in female patients, however, many female patients are unable to pass a straight tip catheter and may find benefit through the use of a coude tip catheter. This experience should be documented in your medical history file. Additionally, some clinicians have determined that using an olive tip coude may be helpful to women in the early learning stages of intermittent self-catheterization.

Question:What if I need more supplies than are allowed in the Medicare/Medicaid/Private Insurance guidelines?

If you need more supplies than are currently allowed under your plans guidelines your physician will need to provide a letter explaining the need for the additional supplies. Your medical supplier will keep this letter on file.

Also, through the establishment of a history of symptomatic recurrent urinary tract infections while on a program of intermittent catheterization you are eligible for a higher quantity of catheters or catheter kits with insertion supplies.

Question: I am currently using straight intermittent catheters but am still having some problems with urinary tract infections. What can I do?

You should talk to your physician/clinician and discuss trying a Closed System intermittent catheter. These products are “touchless” meaning your hands do not have to touch the catheter. These products are reimbursed under an A4353 HCPCS code and require additional documentation.

Question: What are the current HCPCS codes for intermittent catheters?

Question: I don’t have a medical supplier. Can Coloplast help me locate one?

Yes, the Coloplast Customer Help Line at 866-226-6362 can introduce you to an authorized supplier in your local area or an authorized national supplier who will ship your supplies directly to your home often at no charge to you.

Also, we can direct you to a supplier that accepts assignment. A supplier that “accepts assignment” will file a claim on your behalf directly with Medicare. You will be responsible for the 20% co-insurance and Medicare will pay its share of the bill directly to the supplier. Using a supplier that accepts assignment may result in a significant out of pocket savings to you.

Question: I am having difficulty getting my particular Coloplast brand of catheters. What can I do?

All brands of intermittent catheters are reimbursed under Medicare at the same $ allowable. If you ever have problems getting our products, please contact the Coloplast® Care team at 866-226-6362.

Question: My supplier bills Medicare for my product do I have to pay anything?

Yes. A supplier that accepts assignment for Medicare will collect the 20% co-insurance of the Medicare allowable amount for the product you are purchasing. Unless you have a supplemental or secondary insurance plan, you should anticipate having a coinsurance with your Medicare plan.

Question: My supplier is telling me my catheters are not covered and I must pay for them. What can I do?

Intermittent catheters are a covered benefit under Medicare, Medicaid and most private insurance plans. Some Medicaid programs and private insurance plans may restrict how many and what type of catheter you have access to. Coloplast CARE is happy to work with you and your supplier to ensure you have access to the best products and coverage for your catheters.

Question: Where is the best place to get my product if I don’t have insurance?

There are cash based suppliers that offer lower prices for paying cash. They can offer lower prices since they do not have the added administrative expenses that go along with submitting insurance claims. Coloplast works with virtually every supplier of intermittent catheters, and our Coloplast® Care program for intermittent catheter users can help you find an appropriate supplier if you need one.

Question: In an audit of a medical supplier, what information must be contained in the medical record to justify payment for both the type and quantity of urological supplies ordered by the treating physician?

For urological supplies to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. The information should include the patient’s diagnosis and other pertinent information including, but not limited to, duration of the patient’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. Neither a physician’s order nor a supplier-prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician. There must be clinical information in the patient’s medical record that supports the medical necessity for the item and substantiates the information on a supplier-prepared statement or physician attestation.

For intermittent catheterization, in addition to the general information described above, the patient’s medical record must contain a statement from the physician specifying how often the patient (or caregiver) performs catheterizations.

The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or home health agency (HHA) records, and records from other professionals including, but not limited to, nurses, physical or occupational therapists, prosthetists, and orthotists.

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Disclaimer: The information in this document is informational only, general in nature, and does not cover all payers’ rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This document represents no promise or guarantee by Coloplast Corp. regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient’s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-Medicare coverage situations.